Prikaz slučaja Vol. 40 (2015) br. 1. UDK ISSN , 40(2015) br. 1, p COBISS.SR-ID
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1 36 UDK ISSN , 40(2015) br. 1, p COBISS.SR-ID BILIJARNI ILEUS PRIKAZ SLUČAJA GALLSTONE ILEUS CASE REPORT Goran Ilić KLINIČKO-BOLNIČKI CENTAR ZEMUN Sažetak: Uvod: Bilijarni ileus predstavlja mehaničku opstrukciju creva bilijarnim kalkulusom koji u creva dospeva kroz biliodigestivnu fistulu. Retka je komplikacija holelitijaze i čini 1 4% svih ileusa i 25% ileusa kod osoba starijih od 65 godina. Prikaz slučaja: Pacijentkinja starosti 79 godina se javila hirurgu zbog bolova u gornjim delovima abdomena, povraćanja žuto-zelenog sadržaja i izostanka stolice i gasova. Tegobe su počele 4 dana pre prijema. Prednji trbušni zid je bio iznad ravni grudnog koša, mek, neosetljiv. Jetra i slezina su bile nedostupne za palpaciju, a lumbalne lože neosetljive na sukusiju. Kilni otvori su bili slobodni. Peristaltika je bila čujna, bez fenomena pretakanja. Na rektalnom pregledu nije bilo tragova stolice. Rezultati laboratorijskih analiza su ukazali na leukocitozu sa granulocitozom i povišen nivo ureje. Nativni snimak abdomena u stojećem stavu je pokazao postojanje distendiranih vijuga tankog creva sa hidroaeričnim nivoima u ileocekalnoj regiji bez znakova prisustva slobodnog gasa u abdomenu. Plasirana je nazogastrična sonda a pacijentkinja je tretirana intravenskom nadoknadom tečnosti i opservirana. Nakon 8h je ponovljen nativni snimak abdomena na kome nije bilo promena i odlučeno je da se pristupi eksplorativnoj laparotomiji. Intraoperativno je postavljena dijagnoza bilijarnog ileusa, učinjena je enterotomija, ekstrakcija kalkulusa, holecistektomija i reparacija fistule. Postoperativni tok je protekao uredno. Zaključak: Bilijarni ileus je retko kliničko stanje na koje se mora misliti kod starijih osoba sa prethodnom istorijom holelitijaze. Dijagnoza je najčešće intraoperativna, a stopa mortaliteta visoka zbog odložene dijagnoze, starosti pacijenata i prisutnih komorbiditeta. Ključne reči: holelitijaza, starije osobe, bilijarni ileus. Summary: Introduction: Gallstone ileus is a mechanical bowel obstruction caused by a gallstone passed to the bowel through the biliodigestive fistula. It is a rare complication of cholelithiasis and accounts for 1-4% of all cases of mechanical bowel obstructions but up to 25% in patients over 65 years of age. Case report: Seventy-nine-year old female referred to the surgeon for examination. She had been experiencing upper abdominal pain, vomiting of bilous content and the absence of transit of feces and flatus during the previous four days. The abdomen was distended, soft and non-tender. Liver and spleen were not enlarged and renal succussion was negative. There were no signs of hernias. The bowel sounds were present. There was no stool on the rectal examination. Blood tests revealed an elevated total leukocyte count with granulocytosis and elevated blood urea level. A plain abdominal film demonstrated dilated bowel loops and air fluid levels in the ileocoecal region without the signs of pneumoperitoneum. The nasogastric tube was inserted and the patient was treated with intravenous fluids during the observation. Abdominal radiograph done 8h later showed no changes and we decided to perform exploratory laparotomy. During the operation, the gallstone ileus was diagnosed and enterotomy, stone extraction, cholecystectomy and fistula reparation were performed. The postoperative course was uneventful. Conclusion: Gallstone ileus is a rare condition that must be taken into consideration in elderly patients with previous history of cholelithiasis. The diagnosis is usually intraoperative and the mortality rate is high due to delayed diagnosis, advanced age and comorbidities. Key words: cholelithiasis, elderly patients, gallstone ileus UVOD Bilijarni ileus je opturacioni ileus češće tankog nego debelog creva, izazvan većim žučnim kamenom. Nastaje prolaskom kalkulusa kroz biliodigestivnu fistulu, koja se najčešće formira između žučne kese i duodenuma, ređe između žučne kese i kolona, a najređe između žučne kese i želuca. Kalkulus se najčešće postepeno kreće ka distalnijem delu creva i zaglavljuje se u terminalnom delu ileuma 1. Adresa autora: Goran Ilić, Vukova 9, Beograd, Srbija; goran.ilic1976@yahoo.com Rad primljen: Rad prihvaćen: Elektronska verzija objavljena:
2 37 Vol. 40 (2015) br. 1 Prikaz slučaja Bilijarni ileus čini 1 4% svih intestinalnih opstrukcija i nastaje kod 0,3 0,5% osoba sa holelitijazom. Češće se javlja kod žena (3,5 6,0 : 1) i kod osoba starijih od 65 godina kod kojih je uzrok 25% opturacionih ileusa 2 4. Samo 50% osoba sa bilijarnim ileusom je već imalo simptome holelitijaze, a prava je retkost da mu simptomi neposredno prethode 5. Klinička slika bilijarnog ileusa zavisi od mesta opstrukcije, a simptomi crevne opstrukcije obično traju nekoliko dana sa fazama izvesnog poboljšanja kako kalkulus napreduje ka distalnom delu creva 1. Tačna preoperativna dijagnoza bilijarnog ileusa se postavlja u manje od 50% slučajeva 6. Većina pacijenata se operiše pod uopštenom dijagnozom ileusa ili akutnog abdomena, a dijagnoza se postavlja intraoperativno 1. Operacija izbora kod bilijarnog ileusa je enterotomija kroz poprečnu inciziju na nepromenjenom delu creva i ekstrakcija kalkulusa 1. Zbog najčešće odložene dijagnoze, starosti pacijenata i prisutnih komorbiditeta, stopa mortaliteta je i dalje visoka 2 4. Prikazujemo slučaj 79-godišnje pacijentkinje sa kliničkom slikom ileusa zbog opstrukcije distalnog ileuma bilijarnim kalkulusom. PRIKAZ SLUČAJA Pacijentkinja starosti 79 godina se javila opštem hirurgu zbog bolova u gornjim delovima abdomena, povraćanja žuto-zelenog sadržaja i izostanka stolice i gasova. Tegobe su počele 4 dana pre prijema. Pacijentkinja se lečila od arterijske hipertenzije, negirala je druge hronične bolesti i traume. Pre 50 godina je operisana zbog vanmaterične trudnoće. Nije konzumirala alkohol i bila je nepušač. Na prijemu, pacijentkinja je bila svesna, ispravno orijentisana, afebrilna, eupnoična, normalne prebojenosti kože i sluznica, osrednje osteomuskularne građe, teško pokretna i odavala je utisak srednje teškog bolesnika. Na koži prednjeg trbušnog zida je bio prisutan ožiljak od donje medijalne laparotomije, koji je bio uredan, a prednji trbušni zid je bio iznad ravni grudnog koša, mek, neosetljiv na površinsku i duboku palpaciju. Jetra i slezina su bile nedostupne za palpaciju, a lumbalne lože neosetljive na sukusiju. Kilni otvori su bili slobodni. Peristaltika je bila čujna, bez fenomena pretakanja. Na rektalnom pregledu nije bilo tragova stolice. Ostali fizikalni nalazi po sistemima bili su u granicama normale. Rezultati laboratorijskih analiza su ukazali na leukocitozu (14,7x109/l) sa granulocitozom (neu 81,1%), povišen nivo ureje (28mmol/l), a vrednosti transaminaza, bilirubina i amilaza su bile u granicama referentnih. Nativni snimak abdomena u stojećem stavu je pokazao postojanje distendiranih vijuga tankog creva sa hidroaeričnim nivoima u ileocekalnoj regiji. Nije bilo znakova prisustva slobodnog gasa u abdomenu. Rendgen srca i pluća je bio uredan. Plasirana je nazogastrična sonda kojom je dobijeno oko 1,5l biloznog sadržaja. Pacijentkinja je tretitana intravenskom nadoknadom tečnosti i opservirana. Nakon 8h nije bilo subjektivnog poboljšanja, ponovljen je nativni snimak abdomena koji je nije pokazao promene u odnosu na prethodni i odlučeno je da se pristupi eksplorativnoj laparotomiji. Slika 1. Nativni snimak abdomena: 1. kalkulusi u holecisti; 2. dilatirane vijuge tankog creva. 1 2 Posle adekvatne preoperativne pripreme, pacijentkinja je operisana u uslovima opšte endotrahealne anestezije. Nakon pripreme operativnog polja gornjim i donjim medijalnim rezom, otvoren je trbuh nakon čega je učinjena vizuelna i manuelna eksploracija trbušne duplje. Nakon adheziolize verifikovano je postojanje bilijarnog kalkulusa koji je doveo do crevne opstrukcije na nivou terminalnog dela ileuma. Učinjena je enterotomija i ekstrakcija kalkulusa kroz poprečnu inciziju koja je zatvorena pojedinačnim šavovima u dva reda. Daljom eksploracijom je verifikovana fistula između fundusa žučne kese i duodenuma. Nakon
3 38 preparacije elemenata Kalotovog trougla, ligiranja ductus cysticusa i arteria cysiticae, žučna kesa je izljuštena iz svog ležišta i poslata na histopatološku analizu. Posle holecistektomije je učinjena sutura duodenuma i omentoplastika. Nalaz perioperativne holangiografije je bio uredan. Nakon provere hemostaze plasirana su dva drena i rana je rekonstruisana po slojevima. Postoperativni tok je protekao uredno. Patohistološka analiza je pokazala prisustvo hroničnog holecistitisa i fistule oivičene granulacionim tkivom. Slika 2. Perioperativna holangiografija. DISKUSIJA Bilijarni ileus je vrsta opturacionog ileusa koji nastaje opstrukcijom creva solitarnim ili multiplim bilijarnim kalkulusima 1. Bilijarni ileus nastaje kod 0,3 0,5% osoba sa holelitijazom i čini 1 4% svih, i 25% intestinalnih opstrukcija kod osoba starijih od 65 godina. Češće se javlja kod žena (3,5 6,0 : 1) kod kojih je i bilijarna kalkuloza češća 2 4. Prisustvo bilijarnog kalkulusa dovodi do hronične iritacije zida žučne kese i rekurentne inflamacije koja predisponira stvaranje biliodigestivne fistule. Fistula se najčešće formira između žučne kese i duodenuma (60 86%), ileuma i kolona, dok je fistula između žučne kese i želuca retkost 7, 8. Da bi doveo do crevne opstrukcije, bilijarni kalkulus mora biti dovoljno veliki, tj. imati prečnik od bar 2,5cm Do impakcije kalkulusa može doći u bilo kom delu creva, a najčešća je na nivou terminalnog ileuma (60,5%), jejunuma (16,1%), želuca (14,2%), kolona (4,1%) i duodenuma (1,3%), dok u 1,3% slučaja dolazi do eliminacije kalkulusa per vias naturales 13, 14. Terminalni ileum i ileocekalna valvula su najčešća mesta impakcije zbog užeg lumena i nešto slabije peristaltike u odnosu na jejunum 14. Klinička slika bilijarnog ileusa zavisi od mesta opstrukcije. Opstrukcija na nivou duodenuma dovodi do upornog povraćanja (Bouveretov sindrom). Simptomi opstrukcije na nivou distalnijeg dela creva (mučnina, povraćanje, abdominalni bolovi) su obično intermitentni i traju po nekoliko dana kako kalkulus napreduje ka distalnijem delu creva. U početku mogu biti prisutni stolica i gasovi koji sa potpunom opstrukcijom izostaju. Pacijenti se zbog privremenih olakšanja kasnije javljaju lekaru, pa u međuvremenu dolazi do elektrolitnog disbalansa i porasta nivoa ureje u krvi što, zajedno sa drugim komorbiditetima, povećava rizik od kasnijih komplikacija 1. Studije pokazuju da, u proseku, od trenutka nastanka tegoba pa do momenta prijema u bolnicu prođe 1 8 dana 5, 15, 16, dok od prijema do operativnog lečenja prođe 3 4,5 dana 5, 9. Preoperativna dijagnoza bilijarnog ileusa se postavlja u maksimalno 50% slučajeva 6. Najveći dijagnostički značaj ima nativni snimak abdomena u stojećem stavu čija je dijagnostička tačnost oko 50% 17. Klasični nalaz na nativnom snimku podrazumeva tzv. Riglerovu trijadu koju čine: pneumobilija (gas u bilijarnom sistemu); hidroaerični nivoi (radiografski znak delimične ili kompletne crevne okluzije); promena položaja ranije verifikovanog kalkulusa. Prisustvo bar dva elementa Riglerove trijade se smatra patognomoničnim i nalazi se kod 40 50% pacijenata 5. Direktna vizuelizacija kalkulusa je moguća u oko 10% slučajeva, kada je konkrement dovoljno kalcifikovan 17. Ultrazvuk abdomena može pomoći pri dijagnostici bilijarnog ileusa potvrdom holelitijaze, a nekada je moguća i vizuelizacija fistule. Kombinacija nativnog snimka i ultrazvuka abdomena ima senzitivnost od 74% u postavljanju dijagnoze 18. Korišćenje magnetne rezonance (NMR) i kompjuterizovane tomografije (CT) abdomena je doprinelo lakšoj dijagnostici. CT abdomena sa kontrastom ima senzitivnost od 93%, specifičnost od 100% i dijagnostičku tačnost od 93% u dijagnostici bilijarnog ileusa 19. Optimalan hirurški pristup lečenju bilijarnog ileusa je i dalje predmet istraživanja, a
4 39 Vol. 40 (2015) br. 1 Prikaz slučaja izbor adekvatnog pristupa zavisi od lokalnog nalaza, opšteg stanja pacijenta i komorbiditeta. Postoje tri hirurška pristupa: 1. enterotomija; 2. enterotomija sa holecistektomijom koja se izvodi u drugom aktu (two stage surgery); 3. enterotomija, holecistektomija i reparacija fistule (one stage surgery). U poslednje vreme se, u odabranim slučajevima, koristi i laparoskopski asistirana enterotomija sa endoskopskim uklanjanjem kalkulusa kao minimalno invazivna procedura. Zbog uznapredovalih godina pacijenata, komorbiditeta i trajanja crevne opstrukcije preoperativno uspostavljanje balansa tečnosti i elektrolita i kontrola komorbiditeta imaju veliki uticaj na ishod operacije i učestalost postoperativnih komplikacija, bez obzira na hirurški pristup. Enterotomija je najčešće korišćen hirurški pristup zbog najmanje učestalosti komplikacija. Do spontanog zatvaranja fistule dolazi u preko 50% slučajeva 5, 17. Ovo je metoda izbora kod starijih pacijenata sa multiplim komorbiditetima i kod onih sa dužim trajanjem opstrukcije, kod kojih je primarni cilj brza dezopstrukcija creva. Međutim, 5% pacijenata kod kojih je urađena samo enterotomija kasnije imaju neku od komplikacija holelitijaze, a kod 10% će biti neophodna neplanirana reoperacija. Prevalenca rekurencije bilijarnog ileusa na terenu rezidualne holecistolitijaze je između 5% i 17%, a više od polovine rekurencija se dešava u okviru od 6 meseci od inicijalnih tegoba 20, 21. Drugi hirurški pristup podrazumeva enterotomiju u prvom, a holecistektomiju i reparaciju holecistoenterične fistule u drugom aktu, 4 6 nedelja nakon inicijalne operacije. Ovaj pristup se koristi kod mlađih pacijenata kod kojih postoji verovatnoća kasnije pojave bilijarnih komplikacija, ali i kod pacijenata sa rezidualnom holecistolitijazom, kod kojih postoji opasnost od rekurentnog bilijarnog ileusa. Operacija u jednom aktu je najkomplikovanija i ima najveću učestalost intra- i postoperativnih komplikacija. Reisner i saradnici su godine izvršili reviziju 1001 slučaja bilijarnog ileusa i njihovi rezultati su pokazali da je mortalitet kod operacije u jednom aktu 16,9% nasuprot 11,7% kod enterotomije 13. Međutim, ovaj pristup omogućava trajno rešavanje okluzije i bilijarne kalkuloze. Zbog većeg morbiditeta i mortaliteta, ovaj pristup je rezervisan za mlađe osobe, bez značajnih komorbiditeta, kao i za osobe sa aktivnim simptomima bilijarnog refluksa i kalkuloznog holecistitisa. Zbog svega navedenog, jako je bitno intraoperativno isključivanje postojanja bilijarnih kalkulusa palpacijom holeciste, zajedničkog bilijarnog duktusa i celog creva radi odluke o adekvatnom hirurškom pristupu 5, 7, 8. U našem slučaju, odlučili smo se za operaciju u jednom aktu jer se radilo o pacijentkinji bez značajnih komorbiditeta i elektrolitnog disbalansa, inflamiranoj žučnoj kesi i većoj holecistoduodenalnoj fistuli (dijametra oko 2cm) sa enterobilijarnim refluksom. Odlaganje postavljanja dijagnoze, uznapredovale godine pacijenata kod kojih su obično prisutni brojni komorbiditeti, predstavljaju uzroke visoke stope mortaliteta kod bilijarnog ileusa (7,5 15%) 2 4. ZAKLJUČAK Bilijarni ileus je retko stanje u urgentnoj hirurgiji koje se tipično javlja kod starijih osoba, pretežno ženskog pola. Zbog uznapredovalih godina pacijenata i prisutnih komorbiditeta, klinička slika je atipična što doprinosi odlaganju dijagnoze. Korišćenje CT-a i NMR-e olakšava postavljanje dijagnoze bilijarnog ileusa. Enterotomija sa ekstrakcijom kalkulusa je hirurška medoda izbora zbog male stope komplikacija. Mortalitet kod bilijarnog ileusa je i dalje visok. LITERATURA 1. Maksimović Ž. i sar. Hirurgija za studente medicine. Medicinski fakultet Univerziteta u Beogradu, CIBID, Avlund TH, Thomsen H. Gallstone ileus of the colon. Ugeskrift for Laeger 2011; 173 (50): Rodriguez Hermosa JI, Codina Cazador A, Girones Vila J, Roig Garcia J, Figa Francesch M, Acero Fernandez D. Gallstone Ileus: results of analysis of a series of 40 patients. Gastroenterologia y Hepatologia 2001; 24: Loizides S, Reese GE. Gallstone ileus. Internal Medicine Journal 2011; 41 (9): Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J Surg 1990; 77: Beuran M, Ivanov I, Venter MD. Gallstone ileus clinical and therapeutic aspects. J Med Life 2010; 3: Gleen F, Reed C, Grafe WR. Biliary enteric fistula. Surgery, Gynecology and Obstetrics 1981; 153: Abou-Saif A, Al-Kawas FH. Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula,
5 40 and gallstone ileus. American Journal of Gastroenterology 2002; 97: Kasahara Y, Umemura H, Shiraha S, Kuyama T, Sakata K, Kubota H. Gallstone ileus. Review of 112 patients in the Japanese literature. Am J Surg. 1980; 140: Syme RG. Management of gallstone ileus. Can J Surg. 1989; 32: Ihara E, Ochiai T, Yamamoto K, Kabemura T, Harada N. A case of gallstone ileus with a spontaneous evacuation. Am J Gastroenterol. 2002; 97: Al-Obaid O. Gallstone ileus: a forgotten rare cause of intestinal obstruction. Saudi J Gastroenterol. 2007; 13: Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994; 60: Gupta M, Goyal S, Singal R, Goyal R, Goyal SL, Mittal A. Gallstone ileus and jejunal perforation along with gangrenous bowel in a young patient: A case report. N Am J Med Sci. 2010; 2: Warshaw AL, Bartlett MK. Choice of operation for gallstone intestinal obstruction. Annals of Surgery 1966; 164: Schutte H, Bastias J, Csendes A, Yarmuch J, De la Cuadra R, Chiong H, et al. Gallstone ileus. Hepato- Gastroenterology 1992; 39: Doko M, Zovak M, Koplijar M, Glavan E, Ljubicic N, Hochstadter H. Comparison of surgical treatments of gallstone ileus: preliminary report. World Journal of Surgery 2003; 27: Ripolles T, Miguel-Dasit A, Errando J, Morote V, Gomez- Abril SA, Richart J. Gallstone ileus: increased diagnostic sensitivity by combining plain film and ultrasound. Abdominal Imaging 2001; 26: Yu CY, Lin CC, Shyu RY, Hsieh CB, Wu HS, Tyan YS, et al. Value of CT in the diagnosis and management of gallstone ileus. World J Gastroenterol. 2005; 11: Halabi WJ, Kang CY, Ketana N, Lafaro KJ, Nguyen VQ, Stamos MJ, et al. Surgery for Gallstone Ileus: A Nationwide Comparison of Trends and Outcomes. Ann Surg Hayes N, Saha S. Recurrent gallstone ileus. Clin Med Res. 2012; 10:
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